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Adjuvant therapy for vesical neck contractures with triamcinolone injection has given good results with long-term followup but similar results have been obtained with transurethral resection alone in our current re-evaluation. Herein we review 220 consecutive vesical neck contractures treated by the aforementioned modalities.

Endoscopic suspension of the vesical neck was used to prevent urinary leakage in 2 female spinal cord patients with reflex neurogenic bladders, chronic urethral catheters and massive urethral dilatation. Factors responsible for the favorable results are discussed.

To tlu· r."diion: I read 1\ith interest the article by Dr. Jan C. Seski.' "ho correctly emphasized the hazards of placing pPrmanent suture (or any other suture) in the lumen of the bladder. Dr. Seski also suggested that the strength oft he urethral suspension lies only in the "scarring and fixation of the paraurethral fascia" in the retropubic space and implied that this is not enhanced by the use of permanent suture. which may in itself cause osteitis pubis. l am una,vare of any data to support these contentions. Farlv in our experience with Marshall-MarchettiKrantz operations, when absorbable suture material I\· a~ used, we encountered a number of "early failures" \\·it h 1·ecurrence of incontinence six to eight weeks after the suspension. It \\·as noted that the bladder neck and urethra had descended to the original position despite the "scarring and fixation" that we had produced in the retropubic area. Crist and associates have reported similar observations after Pereyra operations in which absorbable suture was used for suspension. For this reason, several years ago we switched to nonabsorbable material and to date we have had no reason to regret it. Osteitis pubis is a condition of unknown cause and, fortunately, of infrequent occurrence, having been noted in only 16 of 549 patients (3 per cent) undergoing operation at our institution. Although most of these operations were done with nonabsorbable materiai (siik and Tevdek), an earlier group for which 0 m No. I chromic catgut was used had an incidence of osteitis pubis of 3 per cent, the same incidence noted by Mat-chetti and associates and others who routinely use catgut. There appears to be no correlation whatsoever between the nature of the material used and the frequency of osteitis pubis. Procedures that eliminate infection and minimize trauma are probabiy of more significance in the prevention of this painful and annoying, albeit infrequent, condition. \\'e continue to favor direct intraoperative assessment of the proximal urethra and vesical neck via a cystotomy performed at operation. This provides additional information regarding the anatomic changes and what may need to be accompiished to restore continence. Of equal importance when one is using nonab~orbable suture material is that the sutures arP placPd Correspondence 709

A case of multiple vesical calculi is presented. There was no history of passing stones, although 1,368 were finally recovered from the bladder. The bladder was not grossly infected. The calculi were uric acid in composition and were not radio-opaque. Removal of the calculi, together with a very small vesical neck resection, provided complete relief of symptoms.

Forty-four consecutive patients, without residual urine or infecttion, were operated upon for urinary stress incontinence by endoscopie suspension of the vesical neck. All patients had preoperative and post-operative lateral view cystograms which showed after operation substantial upward and forward elevation of the urethrovesical junction as measured by the posterior urethrovesical angle, the angle of urethral inclination, and elevation of the base of bladder. Despite a significant history of an urgency component to their incontinence in many patients, as well as 44 previous operations in 22 of the patients, a carefully performed cystometrogram and cholinergic sensitivity test were not helpful in detecting abnormalities of the detrusor muscle. Fourty-one patients were cured, and in three others, the condition was not cured, the failure group. The lateral view cystogram was the most diagnostic test in that two in the failure group did not show preoperatively the roentgenographic hallmark of stress urinary incontinence.

purpose. The injection of corticosteroids into into one end of the polyethylene tube and the the vesical neck may be accomplished with a cut end of the needle hub is fitted into the special needle. Our success utilizing readily opposite end (Fig. 1). The stylet is used to give available materials prompts this report. enough rigidity to enable the insertion of the needle tin into the tissues and is nassed through

The occurrence of vesicoureteral reflux has been recognized for many years. Importance has been attached to its significance as an etiologic factor in upper urinary tract infection and renal damage secondary to back pressure. Extensive studies were made by Graves and Davidoff1in this connection, using rabbits and dogs. Their principal clinical interest was in connection with its relation to upper urinary tract infections. It was not until 1934 that the role of vesicoureteral reflux in the production of renal colic was forcefully brought to attention by Lewis and Carroll,2who presented 30 cases of symptomatic vesicoureteral reflux. All cases described by them were secondary to vesical neck or urethral obstruction, and the symptomatology described was characterized by typical renal colic, occurring usually in the presence of a distended bladder, when the patient attempted to void. Individual cases were presented by several other authors in connection with their

Vesical diverticula represent exaggerated sacculations of the mucous membrane, connected with the general bladder cavity by an opening of variable size. Some writers have expressed the belief that practically all cases are congenital, but latterly there has been a reaction from this position, with a tendency to ascribe most cases to acquired conditions (Lower 1 ), the result of obstruction located mainly at the vesical neck. In the two cases reported herewith the causative relation between obstruction at the vesical neck and the diverticula was plainly shown in the well defined ring of fibrous tissue that surrounded the neck of each bladder; while in the few other cases observed by us, but without being brought to operation, an obstruction was always demonstrable, so that our own inclination is to share belief in the predominance of acquired over the congenital origin of this malady. Englisch 2 based a differentiation between congenital and

It is doubtful that vesical neck obstruction in children is the common cause of urinary infection, reflux, and enuresis. Routine revision of the bladder neck, in association with ureterovesicoplasty, does not improve the cure rate of the antireflux operation. Most agree that it is difficult, if not impossible, to diagnose such obstruction with endoscopy or cystourethrography. Outlet obstruction, through trigonal hypertrophy, tends to further protect the ureterovesical "valve" from incompetency. Voiding pressure studies reveal no significant gradient on either side of the vesical neck. Recent investigations show that the area of increased resistance in young girls is not at the vesical neck but in the midurethra and is caused by involuntary spasm of the periurethral striated muscle. Treatment of the accompanying distal urethral stenosis usually relieves this spasm.

In May, 1920, the cautery punch operation, with infiltration anesthesia of the vesical orifice, was presented by one of us (J. R. C.) before the American Association of Genito-Urinary Surgeons, as a method of removing lesser degree obstructions and attention was centered particularly on the so-called median bar type, which was found, according to a study of pathologic reports by Randall and Lowsley, to be about 14 per cent, of all obstructions at the bladder neck, and from our personal study of 494 clinical cases, to occur in 20 per cent. After concentrating attention on this particular type of obstruction, and becoming more and more familiar with the bladder neck picture, we observed a gradually increasing number of general thickenings around the bladder neck, which were designated as collar obstructions. The various degrees represented different forms of vesical neck contracture and were classified as bars, small, medium and large collars

The purpose of this paper is to discuss some of the most serious complications which have tended to discredit transurethral resection and to suggest certain refinements in the technic of operation which have been demonstrated to avoid them. These complications are, first, infection and sepsis during the immediate postoperative period; second, traumatic stricture of the pendulous portion of the urethra, and, third, persisting urinary dysfunction, with cloudy infected urine, delayed urinary sepsis and occasional recurrent hematuria. Transurethral resection has become an accepted procedure by all urologists, but little agreement exists regarding the indications for and limitations on this operation. Many able and experienced surgeons believe that it should be performed only for small median lobe hypertrophies, median bars and vesical neck contractures. Other genito-urinary surgeons of equal experience and skill in prostatic operations feel that all obstructive lesions of the bladder outlet, regardless of size, should be dealt with by

THE SYNDROME of absence of anterior abdominal musculature and coexisting genitourinary abnormalities is being presented at this time because absence of ganglion cells in the bladder was found in two of our three cases. The suggestion of this as a factor in the origin of megaloureter not associated with absent anterior abdominal musculature has been made by Swenson. 1 Two of our three cases were also interesting because there was definite organic vesical neck obstruction. REPORT OF CASES Case1.—J. G. (No. 244226), a 5-month-old white boy, was first seen at the Bronx Hospital in November, 1951, in an episode of acute laryngotracheobronchitis associated with bronchopneumonia. The absence of anterior abdominal musculature had been noted at birth. Study of the urinary system at another hospital shortly after birth was unsuccessful, but the nonprotein nitrogen value was normal at that time. Examination on admission to this hospital revealed the absence of

The title of this paper is rather all inclusive; however, my object is to review fibrosis (submucous fibrosis) of the vesical neck in children and to report an unusual case of fibrosis with submucous calcification of the vesical orifice in a boy 13 years of age. From a review of the literature it would appear that fibrosis of the vesical neck in children is a rare disease. Campbell 1 reported finding but 12 cases in the literature up to 1930. The disease may be more frequent than the reported cases would indicate, and at times this condition probably goes unrecognized until late in life. Young, 2 in a study of 355 adults with fibrosis of the bladder neck, found 20 cases, or 5.6 per cent, with a history of imperfect urination since childhood, which indicated that the obstruction to urination was probably congenital. Submucous calcification of the vesical neck in

The lower urinary tract has been the subject of intensive investigation for the past decade, during which notable advances have been made particularly in the field of instrumental diagnosis and treatment. With increasing application, certain limitations of these procedures became apparent indicating the need for a supplementary method by which a clearer conception of form and function could be obtained. Urethrocystography fulfils this need and should be used as a part of the routine examination of patients presenting certain lesions of these organs. Although, in our hands, urethrography has proved a valuable diagnostic procedure, its scope is limited as it fails to demonstrate pathologic conditions other than those confined to the urethra and its adnexa. Cystography, while more extensively employed and better understood, also has its limitations. Because of the close anatomic and functional relationship of the posterior urethra, adnexa, vesical neck and bladder muscle, a more accurate concept of

John Caulk 1 in 1921, in a paper entitled "Contracture of the Vesical Neck in the Female," as far as we have been able to find, is the first to suggest resection for bladder neck obstruction in the female. In that paper only 1 case was reported. In 1935 he 2 again called attention to the subject. In 1933 Nesbit 3 reported 2 cases of bladder neck obstruction which he cured by resection. In 1934 Fite 4 reported 1 case in which resection accomplished a brilliant cure. Caulk 5 in 1937 reported a total of 15 cases coming under this classification. Twelve of these were due to inflammatory contractures, 1 the result of lobulations at the orifice cystoscopically similar to prostatic lobes, 1 the result of a subtrigonal hypertrophy and the other a large papillary mass. The Dutch urologist Van Houtum, 6 in an article titled "Prostatism in General and

Since we are now entering a new season of increased incidence of poliomyelitis, this preliminary report is being made regarding the use of furfuryl trimethylammonium iodide ("furmethide") for one of the complications of this disease, paralysis of the bladder. The bladder is involved in 10 to 20 per cent of all patients with poliomyelitis, with more involvement in adults than in children. Usually this is manifested by distention and inability to void, but overflow dribbling may occur, and occasionally there may be hyperirritability of the vesical neck with frequency and dysuria. This disability may be overcome in some patients with the aid of hot applications to the area of the bladder and other nonspecific measures. However, many patients need to be catheterized one or more times before spontaneous voiding reappears, although eventually all do recover. During the 1944 poliomyelitis epidemic in North Carolina we were again impressed with the desirability

To the Editor:— The answer that "once the diagnosis of carcinoma of the prostate has been made, the condition is no longer surgical" is grossly in error. Statistics prove conclusively that carcinoma of the prostate has been cured in a considerable percentage of the cases by a radical operation in which the entire prostate with a portion, of the vesical neck, the seminal vesicles and ampullae of the vasa deferentia have been removed with their fascial coverings in one piece. We have been assiduous in following all patients on whom our operation has been carried out. Some are still well from ten to twenty-six years after leaving the hospital. A meticulous analysis indicates that more than 40 per cent of the patients followed five years or longer after leaving the hospital have shown no evidence of recurrence or metastasis. That in rare instances metastases may become apparent after a longer

Prior to five years ago there were few physicians who believed that much could be accomplished by transurethral operation on the enlarged prostate gland. Caulk, by virtue of long persistence and perseverance, was the first urologist to find that the results obtained with this method in cases in which the prostate gland was quite large were as good as those obtained with operation performed for the removal of small median bars or contracture of the vesical neck. Unfortunately, however, it was none too easy for the large majority of urologists to visualize the operative field with Caulk's punch and, in addition, many were frightened by the severe hemorrhage and postoperative reaction that often followed their unskilful maneuvers. It was therefore not until Stern invented the electroresectoscope, which later was modified by Davis and McCarthy, that most urologists could be induced to attempt transurethral operations except in rare instances. The stimulus

PROSTATIC INCISOR The pathologic reality and the various serious consequences of the condition known as contracture of the vesical neck are now well established. Endeavors to overcome the obstructive effects of this condition have been made by numerous authors, among whom are the following: Bottini, by the galvanocautery blade introduced through the whole urethra; Chetwood, by the same method applied through a perineal incision; Young, by punching out a section of the constricting neck. And Bugee has used high-frequency fulguration with the ordinary insulated wire. Two years ago or longer the desirability of opening the constricted channel without the perineal urethrotomy of Chetwood, or the strong tendency to hemorrhage induced by the punch operation of Young, was impressed on me. It was thought that some mode of applying fulguration more effectively than could be done by the wire was the desideratum. An iridoplatinum blade suggested itself. With the assistance of

There has been a tremendous wave of excitement and enthusiasm about vesical neck resection, which has swept the whole country. It seems to me most appropriate to stop and take stock to see whether such an avalanche of cases is justified. A great deal of attention has always been paid to obstructions at the vesical orifice. A knowledge of the presence of the prostate gland and its abnormalities was known to the ancients. The history of early efforts to relieve prostatic obstruction by various instruments has been presented so often of late that a repetition here is unnecessary. Suffice it to say that the instruments were so inadequate and operations on the prostate improved in quality so materially that open surgical operations on the prostate were the procedures of choice. The development of safety factors and the resultant low mortality in this procedure cannot be carelessly laid aside on the

In the last decade the technic of intra-urethral operations for obstruction of the vesical neck has been greatly improved, as evidenced by the contributions of many authors. Numerous instruments have been devised, which not only have simplified this form of surgery but have led to greater knowledge of the pathologic anatomy of the posterior urethra and vesical neck. As a result, various procedures for the correction of disease not strictly obstructive in nature naturally have developed. In 1931 we were finding various prostatic and posterior urethral lesions which seemed suitable for correction by minor procedures such as electrocoagulation, or incision with the electrocautery. One of us1has reported some of these cases. Removal of prostatic calculi by transurethral methods has been recorded by Michel,2and incision of large, subacute abscesses of the prostate gland by Multhauf and Curtis.3Heitz-Boyer4stated that as early as 1920 he

To the Editor:— In reading the paper on "Treatment of Acute Nephritis" by Drs. Francis D. Murphy and Bruno J. Peters (The Journal, January 17) we were surprised that mention was not made, in discussing the etiology, diagnosis, treatment and prognosis, of obstructing lesions in the ureter, at the vesical neck or in the urethra. It is difficult for a urologist to understand how it could be that some of the 205 patients in their study did not have an obstructing lesion which played a part in making the kidney vulnerable for the toxic agent that brought on the acute glomerular nephritis. Drs. Murphy and Peters say "Why some patients who have recovered from acute nephritis are completely healed and others progress gradually into the stage of chronic nephritis is an unsolved problem." Might not an obstructing lesion be at least one of the factors which caused 43 per cent

Fibrosis of the vesical neck, often called "contracture" of the neck of the bladder, is an obstruction at the vesical orifice, and is produced by the contraction of fibrous tissue which has replaced the muscle fibers of the internal sphincter and the adjacent bladder and urethral walls. This type of obstruction was described as early as 1856 by Mercier.1From a review of the literature it is quite evident that some writers have confused this condition with other types of obstruction, such as atrophic prostate, valves of the prostatic urethra, hypertrophy of the trigon and so-called atony of the bladder. Indeed, today these cases are classed by some as median bar obstruction. It is my belief that the term "median bar" should be applied to elevations which occur on the floor of the bladder, from the immediate bladder neck to the edge of the trigon, including enlarged subcervical glands

The pathology and treatment of obstructions at the vesical neck in women and the inflammatory conditions that lead up to them have received scant attention in the American literature. Two years ago I was able to collect and present thirty-six cases. I showed that the development of hesitation, difficulty in starting micturition, slowness of the stream, irritation, pain, hematuria and the presence of more or less complete retention of urine are quite similar to those conditions in men. On cystoscopic examination the mucosa of the urethra and adjacent portion of the trigon is inflamed, often edematous or even papillomatous. The trigon sometimes hypertrophies as a result of the obstruction. The bladder becomes trabeculated and sometimes cellular from back pressure and increased activity of the detrusors. Impairment of renal function may result from residual urine and back pressure effects on the ureteral orifices and the consequent dilatation of the ureters, pelves

In considering prostatic hypertrophy and the consequent urinary obstruction, it is important for us to know the amount of intravesical hypertrophy. It is often the enlargement of the part around the vesical neck projecting into the bladder in a snoutlike mass, rather than the lateral lobes, that causes the urinary obstruction. Rectal palpation usually affords little, if any, information as to the extent of this intravesical hypertrophy. This can be determined, of course, by cystoscopic examinations, but such procedures are not always feasible or expedient, owing to the age and feeble condition of the patients we are called on to attend. We have recently found that air cystograms with the patient lying face downward clearly demonstrate these intravesical snouts, median lobe enlargements, and similar conditions. While air and oxygen have been used in demonstrating the size of tumors of the bladder, sacculations, and the like, we have not been able

This is a study of 37 women who complained of urinary retention but had no objective evidence of organic disease to account for it. The onset of retention was temporally related to medical or psychologic trauma. Usually these women had multiple somatic complaints and had undergone multiple surgical procedures. From the psychiatric viewpoint, these women were severely ill emotionally, with conversion hysteria and schizophrenia as the most common diagnosis. Psychologic tests supported this concept. Vesical neck resection was not successful in relieving the retention. Treatment should be managed by psychiatrist and urologist working together.

In previous articles one of us 1 has emphasized that in most cases of vesical atony it is extremely difficult and often impossible to state with accuracy whether the vesical dysfunction is a result of primary neurogenic atony, neurogenic atony complicated by obstruction of the vesical neck or myogenic atony secondary to obstruction of the vesical neck. By means of illustrative cases in these previous papers it was shown that even though the most careful cystoscopic, cystometric and neurologic examinations are performed they often fail entirely to supply the correct answer to this diagnostic problem. It was brought out also that the etiologic differentiation of these conditions may be relatively unimportant as far as treatment is concerned. This subject assumes considerable importance when patients who are suffering from tabes dorsalis are concerned. The classic description of the pathologic changes found in this disease are "chronic inflammation of the posterior spinal